Repackaging Death as Life –
The Third Path to Imposed Death

Presented at the
2nd Annual Life Conference
Raleigh, North Carolina, October 23, 2010

A major transformation of traditional medical ethics is taking place. What was once unthinkable has become acceptable, and no one really knows why. In the last half of the 20th century a multi-million dollar social engineering and marketing project financed by foundations and directed by bioethics think tanks has normalized the withdrawal of ordinary care.

History

Let’s look to the first organized euthanasia movement in America which emerged in the 1930s and was known as the Euthanasia Society of America. Its strategy was first to secure legalization of passive euthanasia as a way to prepare public opinion to accept active euthanasia, commonly known as physician assisted suicide. But there were conflicts within the movement and by 1980 there came to be two distinct wings when the more militant branch split off. The militants call themselves the Hemlock Society, Death with Dignity and Compassion and Choices. This wing advocates for physician assisted suicide.

The more nuanced wing, which is a continuation of the Euthanasia Society of America, gave itself more beneficent-sounding names which included Society for the Right to Die and Concern for Dying in the 70s and 80s, Choice in Dying in the early 90s, Partnership for Caring in the late 90s and Last Acts Partnership in the early 2000s. This wing claimed to be against physician assisted suicide. An important piece of the puzzle is that Ira Byock, then president of the American Academy for Hospice and Palliative Medicine, joined with Choice in Dying in 1998 to help form Partnership for Caring.

It may appear that this more nuanced wing ended when Last Acts Partnership dissolved itself in 2003. But many of the Last Acts Partnership people can now be identified throughout the new medical subspecialty called “palliative medicine.” Others can be identified working for a new group at the National Hospice and Palliative Care Organization called Caring Connections.

Today we shall focus on the more nuanced wing of the euthanasia movement. It presents itself as the alternative to physician assisted suicide, thereby bringing us a false sense of security, but all the while working to transform how we die. It is a movement to control death and call it “improving” End-of-Life care.

Third Path and Bioethics

In her 2005 book Terri’s Story: The Court-Ordered Death of an American Woman, author Diana Lynne describes it as the “third path” to death: not wholly natural, not suicide, but something in between.

The “third path” has many similarities to the Third Way political movement of the 1930s in Europe. Both are governed by a utopian and authoritarian philosophy. They believe that there are no absolute principles, nothing is fixed. They seek to triangulate and settle on the middle ground between identified extremes. They operate by building consensus, binding people together for the sake of the “public interest”. The individual is secondary.

Listen to how Daniel Callahan, a major “third path” proponent, described the problem in 1983: “Denial of nutrition, may, in the long run, become the only effective way to make certain that a large number of biologically tenacious patients actually die,” … And (he observed that) a “deep seated revulsion” exists over the prospects of withholding or withdrawing nutrition and hydration.

In late 1984, a story appeared in the New YorkTimes. It is important because it described how both wings of the right-to-die movement and emerging bioethics think tanks such as the Hastings Center, led by Daniel Callahan, were working TOGETHER to change attitudes and behavior…working to change the culture…painting the issues in terms of compassion versus technology.

Today bioethics is embedded in formal governmental regulations, state and federal laws, and medical ethics guidelines around the world. Bioethics is a subfield of ethics that was “created” in 1978 by the Belmont Commission and it quickly became internationally accepted. From its philosophic base has come the utilitarian (and futilitarian) culture that now threatens to permanently change the culture and practice of medicine.

Earlier this year Pope Benedict XVI discussed a fundamental problem with bioethics in his address to the Pontifical Academy for Life. He said, ”some ethicists warn that modern bioethics is in fact a new normative system of ethics that, based on principles of utilitarianism, can never be compatible with Natural Law principles.

In the last few decades (Bioethics) has largely supplanted traditional, Natural Law-based medical ethics in hospitals and ethics boards in most western countries.” He continues,

“Under traditional medical ethics, the guiding principle is ‘do no harm.’ But contemporary bioethics abandons this…in an effort to find the utilitarian goal of the ‘greatest good for the greatest number.’ Under these principles, preserving the life of the human patient is not considered paramount.”

Strategy and Program Design

Have you noticed that people in this more nuanced wing of the euthanasia movement seem to be working from the same set of talking points?

Everyone should have an advance directive to protect himself from unnecessary medical treatment at the end of life.

Withholding/withdrawing food and water is a natural – and even pleasant – way to die, and is a perfectly ethical means of controlling the time of death.

“The principle of double effect” can be used to justify terminal sedation.

The people who are talking these points are financed by powerful foundations.

Among the major foundations spearheading this effort are 1) the Robert Wood Johnson Foundation, which funded the research, and infrastructure, and 2) George Soros’ Open Society Institute/Project on Death in America, which funded a cadre of professionals. In the last 10-15 years these two foundations provided well over $300 million to advance the integration of their version of palliative care into the American health care system.

In the mid-1980s, Robert Wood Johnson Foundation invested in a carefully designed multi-year research study on how Americans were being cared for at the end of their lives. The SUPPORT study which stands for The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment launched the RWJF/Soros initiatives.

The SUPPORT study was conducted on nearly 10,000 patients in five University hospitals including Duke Medical Center. In a sense, SUPPORT was a failure. It attempted to prove that with adequate communication they could change how people die…get people to fill out living wills and forego treatment. But it didn’t work.

So the researchers and their foundations used the data to make their case for changing the entire medical system, as well as shaping the popular culture. SUPPORT brought media and academic journal attention to a purported need for “improvement” in end of life care. The desired changes identified at that time in the mid-90’s were:

1) develop a new subspecialty of palliative medicine,
2) relax constraints on prescription of opioids,
3) invest in palliative care research,
4) revise textbooks to include core content on palliative care, and
5) make professional education in palliative care mandatory.

Their intent was to change the culture of medicine away from its traditional focus on cure.

Five years after RWJF began the SUPPORT study, in the mid-90s George Soros entered the field with a press release that claimed there was a profound “denial of death” in America. The “third path” movement rapidly coalesced.

Soros’ Open Society Institute/ Project on Death in America began funding a Faculty Scholars Program which provided a leadership base for promotion of palliative care into mainstream medicine. PDIA Faculty Scholars in over 50 medical schools developed into a network of colleagues and now the second generation of scholars are committed to institutional change.

Among their first projects directed at professionals were EPEC (Education for Physicians on End of Life Care) and ELNEC (a similar program for nurses). Some of the other projects were directed at changing the general culture including RC EPEC (tailored to Roman Catholics) and APPEAL (tailored to African-Americans).

In 1996, RWJF formed Last Acts, a coalition of over 100 professional and consumer organizations. The first Last Acts Leadership Conference on March 12, 1996 brought 140 national leaders to Washington, DC. In a special supplemental report by the Hastings Center which summarized the conference, Daniel Callahan described their three-pronged strategy moving forward:

Change the education of health care professionals

Change health care institutions and public policies and regulatory apparatus

Engage the public to gain support

RWJF began financing and coordinating statewide end-of-life coalitions or Community-State Partnerships using established state ethics committees, networks and centers in more than 20 states.

The National Program Office for the C-SPs (Community-State Partnerships) was Midwest Bioethics Center (now known as Center for Practical Bioethics), a bioethics “think tank” in Kansas City. Each grant recipient received a sizable $450,000 from RWJF and an additional $150,000 in matching funds. These EOL statewide coalitions pursued the primary goals of educating, training, advocating and changing statutes at the state level.

Which brings me close to home. How did LifeTree become interested and active in advocating for the very sick and chronically ill?

It turns out that the Carolinas Center for Hospice and End of Life Care directed the Community-State Partnership grantee in North Carolina and they were visibly involved in 2003, lobbying in support of a bill which LifeTree opposed.

On its surface, the bill criminalized Physician Assisted Suicide (the radicals’ agenda) but also would have validated “third path” tactics by permissive language in the same bill which validated the withholding/withdrawing life sustaining procedures and prescribing pain medication which hastens death as long as the intent is not to hasten death. LifeTree worked to eliminate these permissive exceptions in the bill and, when it became redrafted more like the Michigan statute which was enacted to stop Dr. Kevorkian, we were surprised to find out that The Carolinas Center and other groups then worked to kill the bill. After it became much clearer and an effective deterrent against hastened death, it never came up for a vote.

A few years later another bill caught our attention. You will recall that the SUPPORT study found that living wills had no measurable impact on the care actually received. And so it was that in 2007 LifeTree worked to oppose a bill that drastically expanded the conditions that would trigger the living will and health care power of attorney and introduce a new type of advance directive called the POLST form. Unfortunately, the bill passed and POLST is currently being implemented in North Carolina!

POLST stands for Physicians Orders for Life Sustaining Treatment. The name says “for” treatment but in fact POLST is much more likely to LIMIT life-sustaining treatment. The POLST form becomes part of doctor’s orders and is prominently displayed in the patient’s medical record wherever the patient goes.

POLST was tested in Oregon in the early 90s and was launched in 1995, one year after Oregon passed legislation legalizing physician assisted suicide. Now, in 2010, over 30 states have endorsed or are developing POLST programs. Only the 20 states in grey on the slide have NO POLST programs to date.

In NC the MOST form, as it is called, can override your Health Care Power of Attorney agent. The form has a lengthy series of boxes to check indicating levels of treatment. Boxes include “Comfort Measures Only,” “No Antibiotics,” “No IV Fluids,” and “Do Not Attempt Resusitation”

A trained facilitator, using carefully designed curricula such as the “Respecting Choices” program, may assist in filling out the form which then becomes part of doctor’s orders, although it can come into effect with neither the patient’s nor a physician’s signature.

Do you remember the discussion of death panels in the proposed Federal health care bill last summer? Did you know that the “consulting sessions” between physician and patient that were to be encouraged and federally funded involved filling out the POLST form?

How do they define palliative care?

To the uninitiated, there might be a common sense understanding of what the words palliative careshould mean and it might go something like this: Managing symptoms and relieving pain.

Many physicians, nurses and other helpers work to do just this and we recognize and applaud them. Many caregivers dedicate themselves to these high principles in a totally ethical way. Unfortunately, because of the movement we have been describing, it is fair to say that Palliative Care, in its true beauty, is now at considerable risk!

As early as 1986, palliative care professionals had signed on to the World Health Organization’s official definition which went well beyond the common sense understanding. By 2006, the official WHO definition had become …”an approach which improves quality of life of patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

With funding from Soros and others, symptom management for the individual patient became broadened to a larger social dimension—ethical decision making, conflict resolution, and spiritual guidance orchestrated by a multidisciplinary team.

The great palliative care marketing achievement is reflected in the evolving nature of the definition of palliative care. Today’s officially defined palliative care is far more than managing a person’s symptoms and alleviating pain. Today’s palliative care is anapproach or a process guided by a trained and certified palliative care team to help the family determine at what point there should be a shift in the goals of care, putting the patient on a different track, away from cure and on towards death.

Recall again what Daniel Callahan said in 1983 about solving the problem of making biologically tenacious patients actually die by withholding food and water. Imposed death is being repackaged as better quality of life.

Critical Juncture in Health Care

We are at a critical juncture in health care as funding moves from private to public sources. For “third path” proponents, end of life care has always included making ends meet within a nationalized health care system. It would appear that this new version of palliative care may be emerging as the “glue” that holds our reformed health care together.

Prior to the passage of the national health care legislation, the unanswered question for the “third path” people had been, “If we build a field of palliative care, will anyone come?” How to convince the American public to accept the curtailment of services? Listen carefully now as they use the marketing technique of selling value. But it will be value based on quality, and quality measured in cost containment.

Let’s look at where we are today – who are some of the "chosen” leaders?

It is no surprise that the person tapped to define “quality” EOL care in the new reformed health care system and to head the Centers for Medicare and Medicaid (CMS) is Don Berwick – the guy made famous by his “rationing with our eyes open” statement.

1. Institute for Healthcare Improvement and Joanne Lynn

Berwick has been defining “quality” for twenty years. He is past president and CEO of IHI, the international Institute for Heathcare Improvement.

IHI focused on end-of-life care from the start. It specializes in bringing together health care organizations to produce guidelines. RWJF funded their Collaborative on End-of-Life Care which set forth three objectives:

1) Institute advance care planning discussions within 24 hours of hospital admission and document the plan in a patient’s chart

2) Reduce the number of transfers to the hospital in the last 2 weeks of life and reduce emergency room utilization

3) Begin bereavement assistance and support for the family and friends before a patient’s death

Berwick chose Joanne Lynn who had directed the SUPPORT Study to chair his IHI End of Life Care Collaborative. Lynn was on the board of Concern for the Dying and made her mark in the 1980s by developing guidelines for withdrawal of treatment. In a Hasting Center Symposium on May 20, 2008 she said, “We need to build a social consensus drawing ona new paradigm that tailors care to the new reality of dying – which is after a long, chronic illness. Not only is it the right thing to do, it makes good business sense.”

We look back to a June, 1997 NY Times story to get a better description of what Lynn believes about total sedation and withholding and withdrawing life sustaining treatment. “When a patient is ready to die, I can stop nutrition and hydration, I can stop insulin and ventilation, I can sedate them. I can creatively collaborate with the forces of nature. But if they really want to control being dead tomorrow at 10, I cannot promise that.”

2. National Priorities Partnership and Christine Cassel

Until his appointment to the Centers for Medicaid and Medicare this summer, Berwick was co-chair of the National Priorities Partnership convened by the National Quality Forum. NPP is a collaborative effort of 28 major national organizations to identify a set of National Priorities and Goals and to help find high leverage areas – those with the most potential to result in substantial “improvement” in the healthcare system. In 2009/2010 the Partners identified Palliative Care and End of Life Care as one of the top five priorities for “improvement.”

Berwick put Christine Cassel in charge of this Palliative Care and EOL working group. Who is Christine Cassel? Cassel is a proponent of physician assisted suicide. She is also president of the American Board of Internal Medicine. With Timothy Quill and Diane Meier she coauthored a 1992 New England Journal of Medicine article entitled, “Care of the Hopelessly Ill: Proposed Clinical Criteria for Physician Assisted Suicide.”

With funding from George Soros, Cassel and Diane Meier co-founded the Center to Advance Palliative Care (CAPC as it is known). CAPC aggressively markets the new sub-specialty of palliative medicine and trains people at nine Palliative Care Leadership Centers around the United States.

Let’s go back to the Euthanasia Society of America chart. Byock, Lynn, Cassel and Meier were all members of Choice in Dying and Concern for Dying. Where are they today? Lynn and Cassel are working with Berwick; Meier is advising a special Senate committee; and Byock is blogging at the New America Foundation and giving high profile interviews with the media.

Given this clear agenda it is no longer safe to assume that palliative care is still just about treating a patient’s symptoms. If that were so, why would there be a need for an entirely new subspecialty in medicine administered by a multidisciplinary team? Why must there be palliative care centers? What do they teach in these centers?

In closing, I would like to address the concerns of those who simply find it hard to believe that palliative care could be one of the reasons things are going wrong in the field of medicine.

I don’t think we can ignore the evidence of the funding and the stated agenda of the recipients of that funding.

Let me conclude with another quote from the 2005 Hastings Center Special Supplement Report written shortly after Terri Schiavo died. The author of the Preface complained:

“What progress has been made is now in danger of being undone. The framework of principles for legitimate decision-making at the end of life built by the courts, the legislatures, and in professional and ethical literature has not been embraced—indeed, it has been rejected, at least in large part – by increasingly powerful and vocal minorities; and political support for this framework, as well as its intellectual justification, seems to be eroding. This is a CRITICAL PROBLEM.”

And so I say to everyone here today: Continue to be part of the problem! – We are making a difference. Become more educated and stay firm.

The Natural Law, which values respect for each life as a unique gift from God, is etched into our hearts by our Creator. Through education, prayer and surrender we can identify and resist the moral pitfalls placed in our way by “third path” proponents who are working to create and institutionalize a palliative care paradigm that does not adhere to the Divine Plan. This will require vigilance and firm adherence to moral principles.

In a culture which truly respects each life, death will never be imposed. In a culture which values life only on a utilitarian scale and in which resources become scarce, each person who faces a life-threatening or chronic condition will find that life endangered. This will be especially so among the elderly, as imposed death will be offered as the morally ethical choice. We must arm ourselves with the truth so that we are able to reject EVERY effort to impose death